PrEP: Ethical questions and key concerns 

The possibility of PrEP being effective raises several ethical questions and concerns: Who will have access? What about drug resistance?

Ethics and Concerns about PrEP

Even before we know whether or not PrEP (Pre-Exposure Prophylaxis) will work, there are some tough ethical questions that PrEP raises as a conceptual idea for prevention. Why ask them now? Because while the research is still underway, we have a chance to shape how it might be integrated into our communities. Also, because we want to ensure that there's an equal chance for everyone who is HIV negative to stay negative, as well as support community members who are HIV positive to thrive.

How could PrEP affect HIV disparities?
It is well documented that while HIV can affect anyone, some communities continue to be hardest hit by this epidemic. It’s taken a larger toll on gay and bisexual men, transwomen and on communities of color, including Black gay and bi men. This disproportionate impact is a result of social stigma and discrimination, economic disparities and lack of access to healthcare.

If taking a pill-a-day does work and providers start prescribing it, the only people who are likely to access it at first will be those able to pay for it out-of-pocket. Without a government mandate, insurance companies won’t be compelled to cover the costs for HIV medications used by HIV negative people to reduce their chances of becoming infected. If this happens, the existing economic and racial disparities between those who have HIV, and those who don’t, could be increased. 

Could PrEP affect the availability of meds for people who are HIV positive?
The thought of making PrEP accessible to HIV negative individuals when not everyone who is HIV positive can access treatment raises a lot of concern.
As The New York Times recently reported, here in the US, we have people who need access to treatment who still can’t get it. Several states are running waiting lists for the federal AIDS Drug Assistance Program, which allows economically challenged people to either get their meds at a reduced cost or for free. It’s estimated that over 1,800 people are on those wait lists. There is also the global context to consider: many people do not have access to HIV medications.  What are the plans for ensuring access to people who are HIV positive?

Could the use of PrEP lead to increases in drug resistance?
No one is expecting that PrEP will be 100% effective in preventing HIV infection, not even condoms are 100% effective.  Therefore, it will be critical that anyone taking PrEP get tested regularly so that they can know their status.  This is important for many reasons:

  • The current PrEP trials are using medications at levels that are not considered adequate to treat HIV infection.
  • If someone on PrEP becomes positive, they will need to immediately need to stop taking a drug regime that’s inefficient to treat HIV disease.
  • If they continue taking PrEP, there is a chance of developing drug resistance.
  • If drug resistance did develop, there is a chance that they could infect someone with a strain of HIV resistant to that drug or drug class.

In this scenario, an ethical question arises: How do we weigh the potential public health benefits of PrEP with the potential public health risk of increased drug resistance?

Some argue that we should continue to only use existing methods like condoms. They are cheap, they work, there’s no possible toxicities or side effects. If it is proven effective, we would like to think of PrEP as another potential tool in the HIV prevention toolbox. The tools that we have now aren’t sufficient or we’d have licked this epidemic already. So, we need to be strategic about how other tools can be integrated into the mix.

Will PrEP take money from other prevention resources?
No one knows for sure yet but CDC has said they won’t fund medications to help prevent HIV. It may be up to local or state health departments.  Some advocates are considering whether new finance mechanisms may need to be developed.

Keeping PrEP in context.
It may seem like it’s the next new thing in HIV prevention, if it works, but we have to remember that condoms are effective, cheap and widely available.  Even if PrEP is successful, it’s unlikely that it would supercede condoms as the most effective prevention method. PrEP may be an effective complement to the range of existing HIV prevention strategies such as condoms, harm reduction, HIV status awareness, syringe access, and behavior change.

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